Statement of Deficiencies

Statement of Deficiencies	(X1) Provider/Supplier/CLIA Identification Number 757188	(X3) Date Survey Completed 02/13/2025
Name of Provider or Supplier Simple Touch Home Health Care, Inc	Street Address, City, State 5250 Santa Monica Blvd Suite 211, Los Angeles, CA
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.

(X4) ID Prefix Tag

Summary Statement of Deficiencies

(Each deficiency should be preceded by full regulatory or LSC identifying information)

G1022

Discharge and transfer summaries
CFR(s): 484.110(a)(6)(i-iii)

(i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer.

This ELEMENT is not met as evidenced by:

Based on interview and record review, the home health agency (HHA) failed to follow their discharge policy by not completing the discharge summary (a written document by a health facility that includes the reason for discharge, the patient discharge condition, and patient and family instructions) within 72 hours of discharge from home health service for two of 7 sampled patients (Patient 3 and Patient 7).

This deficient practice had the potential to result in miscommunication that can affect the care and services needed in the continuation of care for the affected patients.

b. During a review of Patient 7's Face Sheet, the Face Sheet indicated a start of care date (SOC) date of 4/25/2024.

During a review of Patient 7’s Home Health Certification and POC for the certification period from 10/22/2024 to 12/20/2024, the POC indicated Patient 7’s diagnosis which included spondylosis (age-related wear and tear of the spinal disks), hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long time), and chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing). The POC included an order for the skilled nurse (SN) to visit the patient once a week for 9 weeks to perform skilled assessment and evaluation of all body systems, assess vital signs (measure the basic functions of the body that includes body temperature, blood pressure, pulse and respiratory [breathing] rate), and to perform medication reconciliation once a week and inform the agency of any changes in medication regimen.

During a concurrent interview and record review, on 2/13/2025 at 12:45 p.m. with the DPCS, the DPCS reviewed Patient 7’s clinical records. The DPCS stated Patient 7 was discharged on 12/20/2024 due to goals have been met. The DPCS stated there was no documented evidence in Patient’ 7s electronic health record a discharge summary was completed and signed by a registered nurse. The DPCS further stated a discharge summary should have been completed on the day the patient was discharged from service and will be provided to the patient’s physician.

During a review of the agency’s policy and procedure (P&P) titled, Discharge Summary, dated April 2020, the P&P indicated each patient discharged from a service and/or from the organization will have a written discharge summary completed and filed in the clinical record. The discharge summary and other relevant clinical record documents will be completed and submitted within 72 hours of discharge from service.

During a review of the agency’s P&P titled, Contents of Clinical Record, dated April 2020, the P&P indicated a clinical record will be maintained for each patient receiving care. The following information will be available in the clinical record for patients receiving skilled care…. Transfer/discharge summaries and other summary reports sent to the physician, as required by law and regulation and organization policy. The discharge statement shall include the date of discharge, reason for termination of services, and condition upon discharge.

During a record review of Patient 3’s Face Sheet (front page of the chart that contains a summary of basic information about the patient), the Face Sheet indicated a SOC date of 7/15/2024, with a primary diagnosis of alzheimer's disease (a progressive and irreversible brain disorder that gradually destroys memory, thinking and other cognitive functions, eventually leading to dementia).

During a record review of Patients 3’s Home Health Certification and Plan of Care (POC) for the certification period starting from 9/13/2024 to 11/24/2024, with Skilled Nurse (SN) frequency visits of once a week for nine weeks for skilled observation and assessment of all body systems, perform vital signs (measure the basic functions of your body that includes your body temperature, blood pressure [the force of your blood pushing against the walls of your arteries], pulse and respiratory [breathing] rate, pain assessment using pain scale 0-10 (0=no pain, 10=worst pain), and medication compliance and effectiveness.

During a concurrent interview and record review, on 2/13/2025, at 12:30 p.m., with the Director of Patient Care Services (DPCS), the DPCS stated and acknowledged there was no documented evidence a discharge summary was completed for Patient 3 when Patient 3 was discharged on 11 11/2024. The DPCS further stated a discharge summary was not done for Patient 3.

During a record review of the HHA’s (undated) policy and procedure titled, “Discharge Summary,” the policy indicated that the discharge summary and other relevant clinical record documents will be completed within 72 hours of discharge from service.